Severe Acute Malnutrition (SAM)

• Nutritional disorders covered include severe acute malnutrition (SAM), food sensitivity, cow's milk allergy (CMA), lactose intolerance, and failure to thrive (FTT).

Severe Acute Malnutrition (SAM)

• Refers to pathological conditions stemming from an imbalance between nutrient supply and the body's needs.
• Primarily affects children under 5, particularly those aged 6-18 months.
• Responsible for 45% of deaths among children under 5.
• Can be managed with WHO guidelines in a hospital setting that reduces mortality by 55%.
• Causes include lack of food, diarrhea (gastroenteritis), poor sanitation, illiteracy, poverty, and food insecurity.

Types of SAM

• Kwashiorkor presents as edematous malnutrition characterized by swelling.
• Marasmus is severe wasting attributed to calorie and protein deficiency.
• Marasmic Kwashiorkor exhibits combined features of both conditions.

Symptoms and Complications

• Kwashiorkor symptoms include edema, thin wasted limbs, prominent abdomen (ascites), scaly dry skin, skin depigmentation, dermatoses, Vitamin deficiencies, and weakened immunity.
• Marasmus symptoms include severe wasting, aged appearance, no edema, and emotional withdrawal.
• Complications include infections, hypoglycemia, electrolyte imbalance, and refeeding syndrome.
• Kwashiorkor specific complications include vitamin & mineral deficiencies (A, zinc, iron), immune suppression leading to increased infections, and liver/pancreatic issues.
• Marasmus-related complications include unplanned weight loss, muscle loss, low body mass index (BMI), and vitamin and mineral deficiencies.

Therapeutic Management

• Acute phase (1-10 days) involves oral rehydration, diarrhea treatment, and prevention of hypoglycemia and hypothermia.
• Recovery phase (2-6 weeks) involves gradual dietary increase and weight gain.
• Follow-up phase involves outpatient care, developmental stimulation, and monitoring.
• Key treatments include therapeutic foods, vitamin and mineral supplements (Vitamin A, zinc, and copper), and antibiotics for infection prevention.

Cultural and WHO Guidelines

• Breastfeeding is encouraged exclusively for the first 6 months.
• WHO growth standards promote healthy growth habits globally.

Food Sensitivity

• Food allergy is an immune response to specific food proteins.
• Food intolerance is a non-immune adverse reaction.
• Types of reactions include systemic (anaphylaxis, failure to thrive), gastrointestinal (abdominal pain, diarrhea, vomiting), respiratory (cough, wheezing, nasal congestion), and skin (rash, urticaria/hives).
• 90% of food allergies are caused by: milk, eggs, peanuts, tree nuts, fish, shellfish, wheat, and soy.
• Around 6% of children experience food allergies in early years, with peanuts, milk, and shellfish being common triggers.
• Prevention guidelines include exclusive breastfeeding for 4-6 months and early introduction of potential allergens after low-risk foods.
• Diagnosis includes tests like double-blind food challenges.
• Treatment includes avoidance of trigger foods and nutritional counseling to prevent deficiencies.
• Nursing interventions include educating families about symptoms and management, developing a written emergency action plan, and monitoring children in childcare and school settings.
• Medications include epinephrine for life-threatening reactions and antihistamines for mild skin symptoms.
• Children often outgrow allergies to milk and eggs, while peanut and tree nut allergies are usually lifelong.
• Vaccines like MMR are safe for children with egg allergies.

Cow's Milk Allergy (CMA)

• CMA is an immune reaction to cow's milk protein, affecting about 2.5% of infants, with 60% of cases being IgE-mediated.
• Approximately 50% of children may outgrow it by age 3-4.
• Symptoms may appear within the first 4 months, including colic, diarrhea, vomiting, GI bleeding, gastroesophageal reflux, chronic constipation, and sleeplessness.
• Diagnosis is based on history and symptoms along with diagnostic tests include stool analysis (blood, eosinophils), skin prick tests, and serum IgE levels.
• A milk elimination diet with observation of symptom improvement is the best strategy.
• Therapeutic management involves milk elimination, replacing it with casein-hydrolyzed formulas, with alternatives, such as Nutramigen or amino acid-based formulas like Neocate, and reintroduction of milk after 12 months.

Lactose Intolerance

• Lactose Intolerance the deficiency of lactase enzyme needed to digest lactose.
• Symptoms of lactose intolerance include abdominal pain, bloating, flatulence, and diarrhea, typically occurring 30 minutes to several hours after consuming lactose.
• Diagnosis of lactose intolerance is based on history and symptom improvement with a lactose-reduced diet.
• Tests include a hydrogen breath test and stool pH and reducing substances test.
• Therapeutic management involves milk elimination or reduction of dairy products, lactase enzyme supplements, lactose-free or low-lactose formula for infants, and probiotics to improve symptoms by altering gut flora.
• Nursing care for CMA and Lactose Intolerance educate families on dietary restrictions, provide alternatives for calcium sources, monitor the child's growth and development, offer psychological support to parents, and advise on the reintroduction of milk after the allergy resolves.

Failure to Thrive (FTT)

• FTT is inadequate growth due to insufficient calorie intake or utilization.
• Characterized by a decline in height, weight, and head circumference. Results from feeding issues, malnutrition, and lack of parental awareness.
• Indicators include growth dropping more than 2 percentiles from baseline, growth remaining below the 3rd to 5th percentiles, and being less than the 80th percentile of median weight for height.
• Clinical manifestations include growth failure, undernutrition, developmental delays (social, motor, language), behavioral signs of apathy, withdrawn behavior, feeding disorders, avoidance of eye contact, and physical signs like stiff or flaccid posture, minimal smiling, and radar gaze.
• Poor prognosis factors include severe feeding resistance, lack of parental awareness and cooperation, low family income, preterm birth, IUGR, and early onset of FTT.
• Impact of FTT affects brain growth and intellectual development, may lead to lower IQ and motor function, increases the likelihood of behavioral issues, and necessitates long-term follow-up for optimal development.
• Nursing care management includes assessing child's growth parameters (weight, length/height, head circumference), documenting food intake, feeding behaviors, and parent-child interaction; and monitoring for behavioral issues and feeding difficulties.
• Feeding and behavioral patterns include difficulty feeding, vomiting, irritability, and refusal to eat (common), attention-seeking behaviors, and family dynamics that contribute to poor parenting models or a chaotic home environment.
• Assessment and diagnosis involves gathering health, dietary, and perinatal history, assessing physical examination for organic causes (e.g., anemia, lead toxicity), investigating family dynamics, mealtime rituals, and child-parent interactions; and conducting diagnostic tests (e.g., stool analysis, alkaline phosphatase) as needed.
• Therapeutic management focuses on reversing the cause of FTT; in severe malnutrition, prioritize refeeding without causing refeeding syndrome, with a goal for catch-up growth (2-3 times the average growth rate for age) through supplementation with vitamins and addressing coexisting medical issues.
• Interprofessional team for FTT Physicans, nurses, dietitians, occupational therapists, pediatric feeding specialists, and social workers are essential, along with family support through public assistance and referrals, and family therapy and behavioral modification where beneficial.
• Hospitalization and follow-up for severe malnutrition, abuse/neglect, significant dehydration, and failure to thrive despite outpatient management, while many cases can be treated on an outpatient basis with proper intervention.
• Prognosis of FTT depends on the cause of growth failure, with parental education and improving feeding practices being able to reverse growth failure, although long-term studies suggest FTT children may have lower stature, weight, and developmental delays.